Willingness to Pay for Seasonal Influenza Vaccination among Children, Chronic Disease Patients, and the Elderly in China: A National Cross-Sectional Survey

Acceptance and willingness to pay for DTaP-HBV-IPV-Hib hexavalent vaccine among parents: A cross-sectional survey in China

DTaP-HBV-IPV-Hib hexavalent vaccine has been used in high-income countries for many years to prevent diphtheria, tetanus, pertussis, hepatitis B, poliomyelitis, and invasive Haemophilus influenzae type b disease. Currently, no hexavalent vaccines have been approved for use in China. Evidence of parental acceptance and interest in hexavalent vaccines can help policy makers and manufacturers make decisions about entering the vaccine market and the immunization program in China. We measured parental acceptance and willingness-to-pay (WTP) for a hexavalent vaccine to provide such evidence. We conducted a cross-sectional survey of children's caregivers in 16 vaccination clinics in seven cities in China and obtained information on socio-demographics, knowledge of disease, confidence in vaccines, previous vaccination experience, and acceptance of and WTP for hexavalent vaccine. Multivariate logistic regression was used to determine factors influencing acceptance, and multivariate tobit regression was used to identify factors impacting WTP. Between April 28 and June 30, 2023, a total of 581 parents of children aged 0-6 years participated in the survey; 435 (74.87%, 95% CI:71.3%-78.4%) parents indicated acceptance of hexavalent vaccine. Residence location, parents' education level, experience paying for vaccination, and disease knowledge scores were key factors affecting parents' choices for vaccination. Mean (SD) and median (IQR) willingness to pay for full 4-dose course vaccination were 2266.66 (1177.1) CNY and 2400 (1600-2800) CNY. Children's age (p < .001), parents' education level (p = .024), and perceived price barriers (p < .001) were significantly associated with WTP. Parents have high acceptance and willingness to pay for hexavalent vaccine. The less money parents have to pay out of pocket, the more willing they can be to accept the vaccine. Therefore, acceptance may increase even further if the vaccine is covered by medical insurance, provided free of charge by the government, or if its price is reduced. Our results provide reference for optimizing and adjusting immunization strategies in China.

Factors associated with recommendation behaviors of four non-National Immunization Program vaccines: a cross-sectional survey among public health workers in China

BACKGROUND

Immunization is a crucial preventive measure to safeguard children under five years old against a range of diseases. In China, the coverage rate of non-National Immunization Program (non-NIP) vaccines can be improved by leveraging the recommendation from public health workers. Hence, understanding the influencing factors of recommendation behaviors assume paramount importance. This study aims to investigate influencing factors of public health workers' recommendation behaviors towards non-NIP vaccines, with a particular emphasis on financial incentives.

METHODS

A cross-sectional survey was conducted using a multi-stage sampling method in 2019 from August to October. 627 public health workers were recruited from 148 community healthcare centers in ten provincial-level administrative divisions in China. An anonymous questionnaire was used to collect demographic information, attitudes towards vaccination, and recommendation behaviors towards non-NIP vaccines, including Haemophilus influenzae type b (Hib) vaccine, pneumococcal conjugate vaccine, varicella vaccine, and rotavirus vaccine. Descriptive analysis and multivariate logistic regression analysis were adopted in this study.

RESULTS

Of the 610 public health workers with complete survey data, 53.8%, 57.4%, 84.1%, and 54.1% often recommended Hib vaccine, pneumococcal pneumonia vaccine (PCV), varicella vaccine, and rotavirus vaccine, respectively. Logistic regression revealed that gender (Hib vaccine: OR = 0.4, 95% CI: 0.2-0.8; PCV: OR = 0.4, 95% CI: 0.2-0.8; rotavirus vaccine: OR = 0.3, 95% CI: 0.2-0.6), financial incentives for non-NIP vaccination (Hib vaccine: OR = 1.9, 95% CI: 1.1-3.6; PCV: OR = 2.1, 95% CI: 1.1-3.9; rotavirus vaccine: OR = 2.0, 95% CI: 1.1-3.8) and perception of vaccine safety (Hib vaccine: OR = 2.7, 95% CI: 1.1-7.0; PCV: OR = 3.2, 95% CI: 1.2-8.0; rotavirus vaccine: OR = 3.0, 95% CI: 1.2-7.7) were associated with public health workers' recommendation towards Hib vaccine, PCV and rotavirus vaccine.

CONCLUSIONS

The findings highlighted public health workers' recommendation behaviors of non-NIP vaccines in China and revealed strong association between vaccine recommendation and financial incentives. This highlights the importance of financial incentives in public health workers' recommendation toward non-NIP vaccines in China. Proper incentives are recommended for public health workers to encourage effective health promotion in immunization practices.

Better adherence to childhood Haemophilus influenzae type b vaccination with combination vaccines compared to single-antigen vaccines: Evidence from China

Background

The coverage of Haemophilus influenzae type b (Hib) vaccination remains suboptimal in China, and this study aimed to investigate the influencing factors of caregivers' Hib-containing vaccine choices and the association between combination vaccine use and adherence to Hib immunisation schedule among Chinese children.

Methods

From August to October 2019, a cross-sectional survey was conducted in 148 community health care centres from ten provinces in China, which collected vaccination records from 5294 children aged 6-59 months. The children were categorised into three groups based on their Hib-containing vaccine receipt: unvaccinated group, monovalent vaccine group, and combination vaccine group. The outcome measures included: (1) receipt and choice of Hib-containing vaccines, and (2) completion of the three-dose schedule. Multinomial logistic regression was used to evaluate the influencing factors of Hib-containing vaccine receipt and choice, and logistic regression was adopted to investigate the associations between vaccine choice and schedule completion.

Results

Of the 5294 children, 19.53% received monovalent vaccines only, 22.59% received at least one dose of combination vaccines, and 57.88% were not vaccinated against Hib. The overall three-dose completion rate was 27.03%. The multinomial logistic (mlogit) regression findings indicated strong associations of socioeconomic status and Hib-containing vaccine supply with vaccination status. Multiple logistic regression among those who received at least one Hib-containing dose demonstrated a 3-fold increase in the likelihood of three-dose schedule completion by children who received any combination dose compared with those received single-antigen vaccines only (adjusted odds ratio (aOR) = 3.97 (95% CI = 3.14-5.03)).

Conclusions

Findings from the current study provide a more comprehensive understanding of the strong relationship between combination vaccine receipt and completion outcomes. Facing the suboptimal Hib vaccination rate in China, the use of combination vaccines could help increase vaccination compliance, and appropriate government actions to reduce out-of-pocket burden of immunisation are encouraged to address inequities in vaccine choices.

Assessing the impact of the 2018 Changchun Changsheng vaccine incident on childhood vaccination in China

BACKGROUND

The 2018 Changchun Changsheng vaccine incident is an emergent public health event in China with reports of DTaP vaccines with compromised efficacy. This study aimed to estimate the impact of the vaccine incident on real-world vaccination behaviors in China.

METHODS

A cross-sectional survey was conducted in ten provinces in 2019. Vaccination records were collected from 5294 children aged 6-59 months, with information on 75,579 vaccine doses for seven National Immunization Program (NIP) vaccines and two non-NIP vaccines received from 2014 to 2019. Chi-square test, interrupted time series, and logistic regression were used to evaluate the impacts of vaccine incident on vaccination delay, measured as the proportion of delayed doses out of total doses in schedule.

RESULTS

Here we show significant increases in doses delayed ≤ 3 months (19.12% to 22.51%, p = 0.000) and > 3 months (7.17% to 11.82%, p = 0.000) for DTaP vaccine after the incident. By scaling nationally, there will be extra 2.1 million doses delayed ≤ 3 months and 2.8 million doses delayed > 3 months in the year following this incident. More guardians choose expensive private-market substitutes containing DTaP elements over government-funded DTaP vaccines. Controlling for socio-demographic factors, doses scheduled after the incident have higher odds of delays for DTaP vaccine (OR: 3.49, 95% CI: 3.08-3.96) and other NIP vaccines (OR: 2.76, 95% CI: 2.55-2.99), but not for non-NIP vaccines.

CONCLUSIONS

The observed delays in the incident-involved DTaP vaccine immunization reflect the negative effects of the vaccine incident on vaccination behaviors under the NIP. However, its effects seem minimal for non-NIP vaccines.

Estimating national, regional and provincial cost-effectiveness of introducing childhood 13-valent pneumococcal conjugate vaccination in China: a modelling analysis

Background

Although 13-valent pneumococcal conjugate vaccine (PCV13) is available in China's private market, it has yet to be introduced into the National Immunization Programme (NIP) and is therefore not available to large parts of the population. This study aimed to estimate the cost-effectiveness of including PCV13 in China's NIP at national and provincial levels.

Methods

We adopted a decision-tree Markov model to estimate the cost-effectiveness of adding 3-dose PCV13 in the NIP compared to the status quo in the private market from a societal perspective. The model hypothesized a birth cohort for five years after vaccine introduction. Treatment costs and vaccine program costs were calculated from Chinese Center for Disease Control and Prevention (CDC) and national insurance databases. Disease burden data, incidence rate ratios, and other parameters were derived from published and grey literature. Cases and deaths averted, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICERs) were estimated at the provincial, regional, and national levels. One-way, scenario and probabilistic sensitivity analyses were conducted to explore model uncertainty.

Findings

At the national level, introducing PCV13 in the NIP was predicted to prevent approximately 4807 pneumococcal deaths (66% reduction) and 1,057,650 pneumococcal cases (17% reduction) in the first five years of the 2019 birth cohort. Under the assumed base case price of US$ 25 per dose in the NIP, PCV13 in the NIP was cost-effective nationally with ICER of US$ 5.222 per QALY gained, and was cost-effective in 17 and cost-saving in 4 of the 31 provinces compared to the status quo. One-way and scenario sensitivity analyses indicated robust results when varying all model parameters, and probabilistic sensitivity analysis showed a 98% probability of cost-effectiveness nationally.

Interpretation

Our findings highlight the cost-effectiveness of introducing PCV13 in China's NIP. Provincial results supported subnational introduction of PCV13, and priority should be given to less socioeconomically developed provinces. Since vaccination cost is the most influential model parameter, efforts to improve PCV affordability after pooled procurement will benefit public health in a cost-effective manner.

Funding

The Bill & Melinda Gates Foundation.

National and provincial burden of varicella disease and cost-effectiveness of childhood varicella vaccination in China from 2019 to 2049: a modelling analysis

Background

In China, varicella is the third most frequently reported vaccine-preventable infectious disease after tuberculosis and influenza, and imposes a heavy burden on families and society. To inform future immunization policy, we investigated disease burden of varicella in China and explored cost-effectiveness of different varicella vaccination strategies at national and provincial levels.

Methods

A dynamic transmission model was developed to assess disease burden of varicella and the impact of varicella vaccination in China. A cost-effectiveness analysis of three alternative vaccination strategies in China's National Immunization Program (NIP) compared with no vaccination was conducted. Scenario analyses and sensitivity analyses were performed to check the robustness of the results.

Findings

It was estimated that 3.35 million new varicella cases occurred in 2019, more than three times of 982 thousand cases officially reported from National Notifiable Infectious Disease Surveillance System (NNIDSS). The under-reported rate was approximately 71%. The economic analysis revealed that from the societal perspective, the incremental cost-effectiveness ratio (ICER) for one dose of varicella vaccination in NIP was US$ 2357 per QALY at the national level and it was cost-effective in 22 of 31 provinces. The ICER for one dose varicella vaccination plus a mass catch-up for unvaccinated children aged 2-11 years old would be US$ -5260 per QALY, cost-saving at the national level. The one dose plus mass catch-up NIP strategy was also cost-saving in 24 of the 31 provinces.

Interpretation

Varicella incident cases were substantially under-reported in China. Varicella vaccination in the NIP could significantly contribute to reducing the burden of varicella disease. From the societal perspective, including varicella vaccination into China's NIP was highly cost-effective at the national level and in most provinces.

Funding

Bill & Melinda Gates Foundation.

Associations of health literacy with missed free influenza immunization in people with chronic diseases

There is a gap in understanding specific features of health literacy that might be associated with adherence to influenza immunization. The aim of this study was to examine the association of health literacy with avoidance of influenza immunization and beliefs about the influenza vaccine among people with chronic diseases. Selection of study participants was based on a case-control study design in a population of people with chronic illnesses living in the Foča region (Republic of Srpska, Bosnia and Herzegovina) and who were entitled to receive a free influenza shot in season 2017/2018. The cases represented all non-vaccinated people (a total of 146) and the controls were vaccinated people (a total of 149) matched according to town of residence. Participants were interviewed in person from April to December 2018 using a socio-demographic questionnaire, Health Literacy Questionnaire (HLQ) and Health Belief Model Applied to Influenza (HBMAI). Better score on 'Feeling understood and supported by healthcare providers', 'Social support for health' and 'Ability to actively engage with healthcare providers' was associated with more perceived benefits of influenza immunization in men, but not in women. Perceiving more Barriers to influenza immunization was associated with lower scores on 'Feeling understood and supported by healthcare providers', 'Have sufficient information to manage health', 'Social support for health' and 'Ability to actively engage with healthcare providers' in both men and women. Health literacy may be associated with the perception of susceptibility to influenza, benefits and barriers to influenza immunization and motivations to receive influenza vaccine.

The Relationship between Information Dissemination Channels, Health Belief, and COVID-19 Vaccination Intention: Evidence from China

In the context of the ongoing global epidemic of COVID-19 and frequent virus mutations, the implementation of vaccine is the key to the prevention and control of the epidemic at this stage. In order to provide recommendations and evidence to support global epidemic prevention and control and vaccination efforts from the perspectives of health communication and individual psychological perceptions and to improve the vaccination rate of COVID-19 vaccine among appropriate populations, this study conducted a questionnaire survey in eight districts of Beijing and collected a total of 525 valid data points. A health belief model was used to examine the predictors of COVID-19 vaccination behavior, and the relationship between different COVID-19 vaccine information dissemination channels, residents' health beliefs, and propensity to vaccinate was analyzed. This study found the following: (1) among new media, interpersonal communication and traditional media communication channels, the new media channel had the largest number of audiences; (2) the personal health beliefs of audiences in the three information channels differed significantly, with the highest perceived benefits and lowest perceived barriers in the interpersonal communication channel and the highest perceived barriers in the new media communication channel; (3) the health belief model was a significant predictor, with perceived benefits and barriers being the most effective attitudinal variables for predicting vaccination intention. This study is valuable for advancing and improving vaccine communication diffusion research and promoting wider application of the health belief model and communication media in health communication topics.

Analysis on the intention and influencing factors of free influenza vaccination among the elderly people aged 70 and above in Hangzhou in 2022

Background

Although influenza vaccination is recommended for people aged 70 and above in Hangzhou, and the vaccine is provided free of charge, the elderly influenza vaccination rate is still low. The purpose of this study was to understand the barriers and motivations of older people in deciding to receive free influenza vaccine through questionnaires.

Methods

The method of stratified random sampling was adopted to take samples. A questionnaire survey was conducted among the elderly aged 70 years and above by face-to-face interview or telephone interview.

Results

A total of 11,663 elderly people aged 70-100 years were successfully and effectively interviewed. 85.98% of the respondent were willing to get the influenza shot, 8.91% were unwilling to get the influenza shot, and 5.11% were on vaccine hesitancy. The people of age of 70-79 years old (hesitancy: OR 70~79 = 0.668, 95%CI: 0.571 0.782, Unwilling: OR 70 - 79 = 0.755, 95%CI: 0.622 0.916), primary school degree or below (hesitancy: OR Secondary school degree or above = 1.467, 95%CI: 1.249 1.724, Unwilling: OR Secondary school degree or above = 1.255, 95%CI: 1.028 1.535), remote areas (hesitancy: OR near central urban area = 2.111, 95%CI: 1.604 2.778, OR central urban area = 2.957, 95%CI: 2.255 3.877, Unwilling: OR near central urban area = 1.687, 95%CI: 1.230 2.313. OR centralurbanarea = 2.218, 95%CI: 1.626 3.027), and convenient for movement (hesitancy: OR yes = 0.494, 95%CI: 0.420 0.580, Unwilling: OR yes = 0.585, 95%CI: 0.480 0.713), understanding of the free vaccine policy (hesitancy: OR understand = 0.204, 95%CI: 0.171 0.245, Unwilling: OR understand = 0.164, 95%CI: 0.128 0.210), influenza knowledge level≥ 13 points (hesitancy: OR ≥13points = 0.628, 95%CI: 0.533 0.739, Unwilling: OR ≥13points = 0.538, 95%CI: 0.437 0.662), influenza vaccine knowledge level≥ 12 points (hesitancy: OR ≥12points = 0.422, 95%CI: 0.350 0.508, Unwilling: OR ≥12points = 0.370, 95%CI: 0.290 0.472), and social trust level ≥ 12 points (hesitancy: OR ≥12points = 0.134, 95%CI: 0.112 0.160, Unwilling: OR ≥12points = 0.220, 95%CI: 0.180 0.269) are more willing to receive free influenza vaccine.

Conclusion

The proportion of elderly people aged 70 and above who are willing to receive free influenza vaccine is high in Hangzhou. But the level of knowledge about influenza, vaccine and trust in society is low. The government should continue to improve the elderly's awareness and trust in society through medical staff, family members, television and radio media, and guide the elderly to actively vaccinate against influenza. Effective publicity should be carried out through the above channels to guide the elderly to actively vaccinate against influenza.

Public health impact and cost-effectiveness of rotavirus vaccination in China: Comparison between private market provision and national immunization programs

In China, progress to include the RV vaccine in the national immunization program (NIP) is slow. The only two vaccines, the Lanzhou lamb rotavirus vaccine (LLR) and Rotateq, are provided through the private market. This study aims to assess the health impact and cost-effectiveness of using three vaccines in the NIP, Rotateq, Rotarix, and LLR, compared to the status quo. A decision-tree Markov model was adopted to follow the 2019 birth cohort, and a societal perspective was used. Input parameters were based on the latest local data when possible. Outcomes included cases and deaths averted, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICER). Sensitivity analyses and scenario analyses to consider herd immunity and vaccine price reduction were performed. Including Rotateq in the NIP was projected to prevent 348 million RVGE cases (62.6% reduction) and 4251 deaths (72.6% reduction) compared to the status quo. Rotarix through the NIP would prevent 48.7% of cases and 63.2% of deaths, and LLR would avert 20.3% of cases and 22.4% of deaths. The ICERs per QALY gained were US$ 8833 for Rotateq through the NIP, US$ 9503 for Rotarix, and US$ 26,759 for LLR. In uncertainty analyses, the reduction of vaccine prices and the incorporation of herd immunity further improved the cost-effectiveness of the NIPs, especially Rotateq or Rotarix. In conclusion, introducing the RV vaccine in China's NIP is expected to be cost-effective compared to the GDP per capita. Reducing vaccine prices and adopting vaccines with better efficacy would be the future focus.

Parental preference for Haemophilus influenzae type b vaccination in Zhejiang Province, China: A discrete choice experiment

Background

China is the only country in the world that has not included the Haemophilus influenzae type b (Hib) vaccine in its National Immunization Program, making it more difficult to eliminate Hib-related diseases through Hib vaccination. It is necessary to study parental preferences for Hib vaccination to optimize vaccine promotion strategies in China.

Objective

This study aimed to investigate Chinese parental preference for five attributes of Hib vaccination, i.e., the place of origin, effectiveness, adverse event, doctors' recommendation, and the price of full vaccination when making a decision to vaccinate their children under 2 years old.

Methods

A cross-sectional survey was conducted in two cities in Zhejiang Province from November to December in 2020 using a discrete choice experiment (DCE). A mixed logit model was used to estimate participating parents' preference for Hib vaccination attributes included in the DCE. Subgroup analysis and probability analysis were also conducted to capture the heterogeneity and trade-off of parental preference for Hib vaccination.

Results

Data from 6,168 observations were included in the analyses. Parents of children are, on average, more likely to voice a positive preference for Hib vaccination. Such attributes of Hib vaccination as effectiveness and doctor's recommendation have a significant positive influence on parents' preference for Hib vaccination, while imported vaccines, adverse events, and the price of full vaccination have a significant negative influence on parents' preference. Parents with different demographic characteristics also existed heterogeneities in preference for Hib vaccination. Parents will make a trade-off on price if the Hib vaccine has a good performance on effectiveness and safety.

Conclusion

The study found that, regardless of the place of origin of the Hib vaccine, parents with children under 2 years old prefer to compromise on price if the vaccine has a better effectiveness and safety profile. A proactive recommendation from doctors would strengthen their willingness for Hib vaccination. These findings help aid the development of communication strategies with parents for Hib vaccination in China.

Willingness to pay for and willingness to vaccinate with the COVID-19 vaccine booster dose in China

Objective: The present study aims to assess the willingness to pay (WTP) for and willingness to vaccinate (WTV) with the Coronavirus (COVID-19) vaccine booster dose in China when the pandemic is under adequate control and the majority of the population is vaccinated. This study is also to identify significant factors associated with the WTP. Methods: This was a cross-sectional study on adults with no past or present COVID-19 infection. An online questionnaire was distributed to collect data on vaccination status, quarantine experience, and factors related to health beliefs on vaccination. The WTV was assessed through the vaccination preference. The WTP was examined by payment scale (PS) and iterative bidding game (IBG) administered in random order. Three IBG algorithms with different starting-price were presented randomly. The average WTP of PS and IBG were analyzed as primary outcomes using univariate and multivariate analyses. Multivariate ordered logistic regression was performed to identify significant factors for the WTP. Results: The survey recruited 543 participants with a mean age of 32 years and 57.80% being female. The WTV rate was 86.74%, while 94.66% of participants completed full-schedule or enhanced vaccination. The mean WTP was CNY 149 (±CNY 197) and the median WTP was CNY 80. Regarding significant factors for the WTP, urban residents were 57% more likely (95% CI: 1.11-2.22) to pay for a high-priced vaccine than rural residents. Respondents who completed full-schedule vaccination were 46% more likely (95% CI: 1.03-2.07) to pay for a high-priced vaccine than those who completed enhanced vaccination. Respondents with a low household income of CNY 40k or lower were 62% less likely (95% CI: 0.21-0.66) to pay for a high-priced vaccine than those with a middle household income of CNY 110k-210k. Other significant factors associated with the WTP included the perceived benefit of vaccination and peer environmental pressure in the health belief model. Conclusion: The WTV with the COVID-19 vaccine booster dose was high in China. The WTP was influenced by the place of residence, vaccination status, household income, perceived benefit of vaccination, and environmental peer pressure. Study findings can inform policymakers to better design vaccination programs and financial schemes involving out-of-pocket payments.

PPSV-23 recommendation and vaccination coverage in China: a cross-sectional survey among healthcare workers, older adults and chronic disease patients

BACKGROUND

: 23-valent pneumococcal polysaccharide vaccine (PPSV-23) is crucial to protecting high-risk groups. This study aimed to investigate the influencing factors of PPSV-23 recommendation among healthcare workers, and PPSV-23 coverage among Chinese older adults and chronic disease patients.

RESEARCH DESIGN AND METHODS

: In 2019, a cross-sectional questionnaire survey was conducted in ten provinces in China among older adults aged ≥65 years, chronic disease patients aged 18-64 years, and primary healthcare workers. Multiple logistic regression model was adopted to identify the influencing factors of PPSV-23 recommendation and vaccination uptake.

RESULTS

: Of the 1138 healthcare workers, 46.75% often recommended PPSV-23 to target groups, and public health workers were more likely to recommend than general practitioners. PPSV-23 vaccination rate was 3.29% among chronic disease patients aged <65 years, 6.69% among older adults without chronic disease(s), and 8.87% among chronic disease patients aged ≥65 years. Multiple logistic regression revealed that only general practitioners' recommendation was associated with increased PPSV-23 coverage (p < 0.05).

CONCLUSIONS

: The findings highlighted the suboptimal PPSV-23 coverage rate in China and the strong association between healthcare workers' recommendation and residents' vaccination uptake. Targeted and coherent PPSV-23-related training is suggested for general practitioners to encourage effective health promotion in clinical practices.

Factors associated with caregivers' hesitancy to vaccinate children against influenza: A cross-sectional survey in China

BACKGROUND

Seasonal influenza can cause serious harm to children under five years of age, while caregivers are still hesitant to vaccinate children against influenza. This study aimed to investigate caregivers' hesitancy regarding influenza vaccination and assess the associated factors.

METHODS

From August to October 2019, a cross-sectional survey was conducted in ten provinces in China. The questionnaire collected information about sociodemographic characteristics and caregivers' knowledge, perceptions and attitudes toward influenza vaccination. Caregivers were identified as not hesitating, hesitating or refusing to vaccinate children. Multinomial logistic regression was adopted to determine factors related to vaccine hesitancy based on the 3C model with three dimensions namely complacency, convenience and confidence.

RESULTS

A total of 6668 valid questionnaires were collected, among which 38.57% did not hesitate to vaccinate children against influenza, 56.03% were hesitant, and 5.40% refused. Multinomial logistic regression showed that caregivers perceiving high importance (AOR = 0.68 for hesitancy; 0.15 for refusal), safety (AOR = 0.42; 0.46) or efficacy (AOR = 0.73; 0.65) of influenza vaccination, knowing children as a priority group (AOR = 0.80; 0.48), and trusting vaccination advice from medical staff (AOR = 0.65; 0.51) had lower odds of hesitancy or refusal. Those considering price as a hindering factor had higher odds of hesitancy (AOR = 1.66) or refusal (AOR = 1.47), and those viewing time or distance as a hindering factor (AOR = 1.45) or having heard of vaccine-related negative information (AOR = 1.78) had higher odds of hesitancy. Sociodemographic characteristics were associated with vaccine hesitancy or refusal, and the associations varied for hesitators and refusers.

CONCLUSION

A large proportion of caregivers in China reported their hesitancy for influenza vaccination, and the associated factors of such hesitancy were complicated. Health professionals are recommended to spread relevant scientific knowledge and give vaccine-related suggestions to caregivers in doctor visits to promote caregivers' trust in influenza vaccination and therefore expand childhood vaccine coverage.

National, regional, and provincial disease burden attributed to Streptococcus pneumoniae and Haemophilus influenzae type b in children in China: Modelled estimates for 2010-17

Background

Vaccination against Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae type b (Hib) is not included in China's national immunization programme. To inform China's immunization polices, we estimated annual national, regional, and provincial childhood mortality and morbidity attributable to pneumococcus and Hib in 2010-17.

Methods

We estimated proportions of pneumonia and meningitis deaths and cases attributable to pneumococcus and Hib using evidence from vaccine clinical trials and surveillance studies of bacterial meningitis and pathogen-specific case fatality ratios (CFR). Then we applied the proportions to model provincial-level pneumonia cases and deaths, meningitis deaths and meningitis CFR in children aged 1-59 months, accounting for vaccine coverage. Non-pneumonia, non-meningitis (NPNM) invasive disease cases were derived by applying NPNM meningitis ratios to meningitis estimates.

Findings

In 2010-17, annual pneumococcal deaths fell by 49% from 15 600 (uncertainty range: 10 800-17 300) to 8 000 (5 500-8 900), and Hib deaths fell by 56% from 6 500 (4 500-8 800) to 2 900 (2 000-3 900). Severe pneumococcal and Hib cases decreased by 16% to 218 200 (161 500-252 200) in 2017 and 29% to 49 900 (29 000-99 100). Estimated 2017 national three-dose coverage in private market was 1·3% for PCV and 33·4% for Hib vaccine among children aged 1-59 months. Provinces in the west region had the highest disease burden.

Interpretation

Childhood mortality and morbidity attributable to pneumococcal and Hib has decreased in China, but still substantially varied by region and province. Higher vaccine coverage could further reduce disease burden.

Funding

Bill & Melinda Gates Foundation.

Public Perceptions and Acceptance of COVID-19 Booster Vaccination in China: A Cross-Sectional Study

Coronavirus disease 2019 (COVID-19) booster vaccination has been proposed in response to the new challenges of highly contagious variants, yet few studies have examined public acceptance of boosters. This study examined public acceptance of COVID-19 booster vaccination and its influencing factors by using the data from a self-administered online cross-sectional survey conducted in June 2021 in China. Multiple logistic analysis was used to examine the influencing factors of booster acceptance based on the health belief model (HBM). Among 1145 respondents, 84.80% reported to accept COVID-19 booster vaccination. Having COVID-19 vaccination history, perceiving high benefits and low barriers to booster vaccination, being younger (18-30 vs. 41-50), having a lower education level, being employed, and belonging to priority groups for vaccination were associated with increased odds of booster acceptance. The primary reason for refusing booster vaccination was concern about vaccine safety. The vast majority (92.8%) of respondents reported an annual willingness to pay between 0 and 300 CNY (0-46.29 USD) if the booster was not free. Our findings suggest that the acceptance rate of booster vaccination is relatively high in China, and the HBM-based analysis reveals that more efforts are needed to increase perceived benefits and reduce perceived barriers of vaccination to design effective and proper vaccination extension strategies when boosters become widely recommended.

National and provincial impact and cost-effectiveness of Haemophilus influenzae type b conjugate vaccine in China: a modeling analysis

BACKGROUND

Globally, Haemophilus influenzae type b (Hib) vaccine has substantially reduced the burden of Hib invasive disease. However, China remains the only country not to include Hib vaccine into its national immunization program (NIP), although it accounts for 11% of global Hib deaths. We aimed to assess the cost-effectiveness of including Hib vaccine in China's NIP at the national and provincial levels.

METHODS

Using a decision-tree Markov state transition model, we estimated the cost-effectiveness of Hib vaccine in the NIP compared to the status quo of Hib vaccine in the private market for the 2017 birth cohort. Treatment costs and vaccine program costs were calculated from Chinese Center for Disease Control and Prevention (CDC) and national insurance databases. Epidemiological data and other model parameters were obtained from published literature. Cases and deaths averted, quality-adjusted life years (QALYs) gained, and incremental cost-effectiveness ratios (ICER) were predicted by province. Deterministic and probabilistic sensitivity analyses were performed to explore model uncertainty.

RESULTS

Including Hib vaccine in the NIP was projected to prevent approximately 2700 deaths (93% reduction) and 235,700 cases of Hib disease (92% reduction) for the 2017 birth cohort at the national level. Hib vaccine was cost-effective nationally (US$ 8001 per QALY gained) compared to the GDP per capita and cost-effective in 15 of 31 provinces. One-way and scenario sensitivity analyses indicated results were robust when varying model parameters, and in probabilistic sensitivity analysis, Hib vaccine had a 64% probability of being cost-effective nationally.

CONCLUSION

Introducing Hib vaccine in China's NIP is cost-effective nationally and in many provinces. Less socioeconomically developed provinces with high Hib disease burden and low access to Hib vaccine in the current private market, such as those in the west region, would benefit the most from adding Hib vaccine to the NIP. In the absence of a national policy decision on Hib vaccine, this analysis provides evidence for provincial governments to include Hib vaccine into local immunization programs to substantially reduce disease burden and treatment costs.

The Economic Burden of Influenza-Like Illness among Children, Chronic Disease Patients, and the Elderly in China: A National Cross-Sectional Survey

Background: The disease burden of seasonal influenza is substantial in China, while there is still a lack of nationwide economic burden estimates. This study aims to examine influenza-like illness (ILI) prevalence, healthcare-seeking behaviors, economic impact of ILI, and its influencing factors among three priority groups during the 2018–19 influenza season. Methods: From August to October 2019, 6668 children’s caregivers, 1735 chronic disease patients, and 3849 elderly people were recruited from 10 provinces in China to participate in an on-site survey. The economic burden of ILI consisted of direct (medical or non-medical) and indirect burdens, and a two-part model was adopted to predict the influencing factors of total economic burden. Results: There were 45.73% children, 16.77% chronic disease patients, and 12.70% elderly people reporting ILI, and most participants chose outpatient service or over-the-counter (OTC) medication after ILI. The average economic burden was CNY 1647 (USD 237.2) for children, CNY 951 (USD 136.9) for chronic disease patients, and CNY 1796 (USD 258.6) for the elderly. Two-part regression showed that age, gender, whether the only child in the family, region, and household income were important predictors of ILI economic burden among children, while age, region, place of residence, basic health insurance, and household income were significant predictors of ILI economic burden among chronic disease patients and the elderly. Conclusions: A large economic burden of ILI was highlighted, especially among the elderly with less income and larger medical burdens, as well as children, with higher prevalence and higher self-payment ratio. It is important to adopt targeted interventions for high-risk groups, and this study can help national-level decision-making on the introduction of influenza vaccination as a public health project.